Initial Assessment form

PROFILE

Name
Age
Sex
Height
Occupation
Corporate job/ Field Job/
Housewife/ Work from home

WEIGHT & MEASUREMENTS (need to be taken first thing in the morning after visiting the loo)

Weight
Weigh yourself on a digital weighing scale in light clothes
Chest
Place one end of the tape measure at the fullest part of your bust, wrap it around (under your armpits,
around your shoulder blades, and back to the front) to get the measurement.
Waist
Use the tape to circle your waist (sort of like a belt would) at your natural waistline, which is located above
your belly button and below your rib cage. (If you bend to the side, the crease that forms is your natural
waistline.) Don’t suck in your stomach, or you’ll get a false measurement. If you generally wear your
clothes below your waist, take that measurement as well.
Hips
Start at one hip and wrap the tape measure around your rear, around the other hip, and back to where you
started. Make sure the tape is over the largest part of your buttocks. Because making sure the tape is level
back there can be hard, try to do it in front of a mirror

LIFESTYLE PATTERN

Food preference
Vegetarian/ Non-vegetarian/ Egg-eater
Alcohol consumption details
How often/ what type/ quantity at one time/ accompaniments
Smoking details
How many per day/ since how many years/ if stopped, since
how long
Exercise details
What type/ since how long/ what time of the day
Sleep details
How many hours/ rate your sleep/ any sleep issues
Water consumption details
How much in a day/ at what intervals/ do you consciously
drink or only when thirsty/ do you prolong thirst sensation
 MEDICAL HISTORY

Last date of full body check up

Kindly attach the last blood/ body reports along with the form
Past medical history
Surgery/ major illness
Current medication details
Medicine name along with dosage
Body pain/ joint pains
Back/ knees/ shoulder/ neck
Other health concerns
Hair fall/ skin problems/ dandruff/ low immunity/ migraine
Gastric issues
Gas/ acidity/ constipation/ burping

FOR FEMALES

Menstrual cycle (how many days)

Last menses date
Pregnancy details
Delivery date/ delivery type/ any complication during
pregnancy
Weight at your delivery
Currently lactating

MEAL DETAILS (what, when & where do you typically eat)

Meal Time At home/ on Eating options/ preferences

the go/ at
office
Early
morning
Breakfast
Mid-
morning
Lunch
Snacks
Dinner
Post dinner

ADDITIONAL INFORMATION

How many meals in the week do you eat outside

How are your weekends different from weekdays
Which oil do you use
How many cups tea/ coffee do you drink in a day?
With or without sugar?
How do you prefer to eat egg?
Omelet / scrambled/ French toast/ bhurji/ boiled
Do you like paneer?
Do you fast? If, yes please provide details
What can you eat/ which days
Vegetable preference
How do you like your veggies/ which do you dislike
Fruit preference
Do you like eating multi-grains?
Bajra/ jowar/ ragi/ quinoa/ couscous/ brown rice
Do you like eating breakfast cereals?
Do eat biscuits? Which ones? How many at a time?

OTHER DETAILS: